Common Neonatal Problems Research Articles

The newborn with “few red blood cells” and the newborn with “too many red blood cells”

Anemia and polycythemia are common hematologic problems in neonates. Although significant progress has been made in this field, some of the common interventions for these conditions are not yet supported by scientific evidence. With this manuscript we aim to define a structured approach for the diagnosis of these conditions and review their usual treatment.

G151(P) Impact of a Training Programme on Non-Medical Health Workers Confidence in Managing Common Neonatal Problems in Sierra Leone

Background and AimsSierra Leone has one of the highest infant mortality rates in the world, with 113 out of every 1000 live births dying in their first year of life....

Clinical and research issues in neonatal anemia and thrombocytopenia

Anemia and thrombocytopenia are the most common hematological problems in neonates. Red blood cell (RBC) and platelet transfusions are the mainstays of therapy, but data to guide neonatal transfusion practices have been sparse. Recombinant hematopoietic growth factors represent another therapeutic alternative, but their use in this population requires a solid understanding of the developmental differences between fetal and adult hematopoiesis. Recently, follow-up studies from children randomized as neonates to either liberal or restrictive RBC transfusion approaches were published. Results of these studies have so far been contradictory and have generated more questions than answers. New developmental stage-specific problems associated with RBC transfusions were also uncovered, such as the transfusion-associated necrotizing enterocolitis. Finally, two thrombopoietin (Tpo) mimetics were approved by the FDA for the treatment of adults with chronic immune thrombocytopenia, thus offering a novel potential therapeutic alternative for thrombocytopenic neonates. In this review, we will discuss the currently available data regarding neonatal RBC and platelet transfusion thresholds, as well as the potential limitations, and concerns associated with the use of erythropoietin and Tpo mimetics in this patient population. Finally, we will point out specific areas wherein additional research is critically needed.

Impact of Feeding Strategies on the Frequency and Clearance of Acid and Nonacid Gastroesophageal Reflux Events in Dysphagic Neonates

Feeding difficulties and gastroesophageal reflux (GER) are common problems in neonates. The authors hypothesize that GER could be influenced by feeding mechanics by evaluating the effects of feeding volumes, feeding durations, feeding flow rates, and caloric density on the chemical composition and clearance of GER in dysphagic neonates. Symptomatic dysphagic neonates (n = 35) underwent evaluation for suspected GER using pH-impedance methods. The proportions of acid and nonacid GER were different during the first, second, and third postprandial hours (P < .0001). Prolonged feeding duration was significantly associated with decreased total, nonacid GER and BCT (P < .03). Significant positive correlations (P < .05) were detected between feeding flow rate vs frequency of total, nonacid GER and BCT. Significant positive correlation (P = .002) was noted between feeding volume and BCT. BCT decreased with each hourly interval (analysis of variance [ANOVA] P < .05); however, ACT increased with each hourly interval (ANOVA P = .05). Comparison between BCT and ACT at each postprandial hour is remarkable for longer ACT during the second and third hours after the initiation of feed (P ≤ .001). No significant correlation was noted between the milk types (breast milk or formula) or caloric density with regard to the GER characteristics. Oral-fed infants had more GER events than gavage-fed infants. Prolonged feeding durations and slower flow rates are associated with decreased frequency of GER. Modification of feeding duration and flow rate can be a useful adjunct to ameliorate GER in dysphagic neonates.

Healthcare Behavior and Expenditure in an Urban Slum in Relation to Birth Experience and Newborn Care

Newborn care practices and healthcare seeking are important determinants of neonatal morbidity and mortality in the resource-limited settings of the urban slums. To examine the current patterns of healthcare-seeking behavior and estimate out-of-pocket expenditure for delivery and common neonatal problems in the urban slums of Chandigarh. Community-based cross-sectional survey. Structured questionnaire was used to collect data from the clusters selected by the World Health Organisation (WHO) Expanded Program for Immunization's cluster survey method. Independent t-test, one-way ANOVA and Pearson's Chi-square tests were used to analyze the data. All tests were two-tailed and p < 0.05 was taken as significant. 31.7% of the mothers delivered at home with 4.18 ± 2.16 mean number of antenatal visits and 73.9% used prelacteals. Factors significantly predicting home deliveries were identified. About 44.7% of the neonates had problems after birth, with 40.3% requiring hospitalization. Choice of private healthcare providers governed the care seeking in the majority (61.4%). Out-of-pocket expenditure was significantly high for the private care providers in terms of the cost of delivery and the overall cost of neonatal illness though no gender-based differences were seen. Private sector emerged as the major healthcare provider in the urban slums resulting in higher out-of-pocket expenditure. A comprehensive health strategy comprising of health education, improvement in antenatal practices, institutional deliveries, behavior change communication activities and quality perinatal care is required for these urban slums.

A new neurological focus in neonatal intensive care

Advances in the care of high-risk newborn babies have contributed to reduced mortality rates for premature and term births, but the surviving neonates often have increased neurological morbidity. Therapies aimed at reducing the neurological sequelae of birth asphyxia at term have brought hypothermia treatment into the realm of standard care. However, this therapy does not provide complete protection from neurological complications and a need to develop adjunctive therapies for improved neurological outcomes remains. In addition, the care of neurologically impaired neonates, regardless of their gestational age, clearly requires a focused approach to avoid further injury to the brain and to optimize the neurodevelopmental status of the newborn baby at discharge from hospital. This focused approach includes, but is not limited to, monitoring of the patient's brain with amplitude-integrated and continuous video EEG, prevention of infection, developmentally appropriate care, and family support. Provision of dedicated neurocritical care to newborn babies requires a collaborative effort between neonatologists and neurologists, training in neonatal neurology for nurses and future generations of care providers, and the recognition that common neonatal medical problems and intensive care have an effect on the developing brain.

211 G to A Variation of UDP-Glucuronosyl Transferase 1A1 Gene and Neonatal Breastfeeding Jaundice

Breastfeeding jaundice is a common problem in neonates who were exclusively breastfed, but its pathogenesis is still unclear. The uridine diphosphate glucuronosyl transferase 1A1 (UGT1A1) gene polymorphism was shown to contribute to the development of neonatal hyperbilirubinemia. We hypothesize that the variation of UGT1A1 gene may contribute to neonatal breastfeeding jaundice. We prospectively enrolled 688 near-term and term infants who were exclusively breastfed (BF group) or were supplemented by infant formula partially (SF group) before onset of hyperbilirubinemia. Genotyping of the promoter and exon1 of UGT1A1 was performed in all neonates. Neonates in BF group had a significantly higher maximal body weight loss ratio, peak bilirubin level, and a greater incidence of hyperbilirubinemia than those in SF group. Neonates with nucleotide 211 GA or AA variation in UGT1A1 genotypes had higher peak serum bilirubin levels and higher incidence of hyperbilirubinemia than WTs (GG). This phenomenon was only seen in BF group but not in SF group when subset analysis was performed. This suggests that neonates who carry the nucleotide 211 GA or AA variation within coding region in UGT1A1 gene are more susceptible to develop early-onset neonatal breastfeeding jaundice.

Range of Thresholds Used for Treatment of Neonatal Hyperbilirubinemia at Different Gestational Ages across Neonatal Units in Great Britain

Objectives: To review the range of thresholds used for treatment of neonatal jaundice at different gestational ages across neonatal units in Great Britain. To investigate the time at which the threshold values plateau, in terms of hours after birth, for various gestational ages. Methods: We contacted 72 neonatal units in Great Britain and enquired about the unit guidelines for management of neonatal jaundice. We requested a copy of the guidelines and jaundice action charts used. Levels for treatment with phototherapy and exchange transfusion for various times after birth and for different gestational ages were extracted and the data was transferred to an Excel spreadsheet. Identical values were excluded so that there was no duplication of charts. The data was analysed to explore the variation in charts used and the time at which the threshold value reached a plateau was recorded for each chart. Results: Of the 72 units contacted 46 responded with charts. Four neonatal units were using formulas and one hospital was using separate chart for every gestation. The data displayed wide variation in treatment levels (phototherapy and exchange transfusion) at 12 to 168 hours after birth in the three gestational groups studied (28, 32 and 37 weeks). For a term neonate at 72 hours of age the threshold to commence phototherapy varied between 220-370 micromol/l and the exchange transfusion threshold varied between 300-510 micromol/l. A wide variation in practice was seen for all three gestations. The median plateau time was also analysed and for phototherapy this corresponded to 72 hours for all three gestations. For exchange transfusion data the median time of plateau was highest for the term babies (72 hours) and lowest for 32 weeks gestation (48 hours). There was no reference of evidence quoted in the jaundice action charts surveyed. Conclusions: Jaundice action charts reviewed in our study showed significant variation in the threshold for treatment of neonatal jaundice. Both the studied parameters (variation in threshold and the median time to plateau) point towards the fact that the charts being used in the neonatal units are not evidence based and need modification. With the lack of standard treatment guidelines for this common neonatal problem, it is likely that neonatal units are either under or over treating a significant number of babies.

Is Combined Atrial Volumetrics by Two‐Dimensional Echocardiography a Suitable Measure for Quantitative Assessment of the Hemodynamic Significance of Patent Ductus Arteriosus in Neonates and Infants?

Patent ductus arteriosus (PDA) is a common cardiac problem in neonates and infants, but determination of its hemodynamic significance can be challenging. We hypothesized that combined left (LA) and right atrial (RA) volumes physiologically best reflect hemodynamically significant patent ductus arteriosus (HSPDA), and utilized two-dimensional echocardiography (2DE) derived atrial volumes to test this hypothesis. 2DE examinations with good-quality images in 138 neonates <3 months corrected gestational age with PDA, and 50 normal neonates without PDA were selected. Measurements of LA, RA, and combined atrial volumes were performed, in addition to transductal diameters, left atrial to aortic dimension (LA:Ao), and left ventricular end-diastolic to aortic dimension ratios. An experienced cardiologist, blinded to 2DE images of atria and ventricles and to the above measurements, independently assessed HSPDA based only on images and Doppler data of the ductus itself, thus identifying each PDA as of low hemodynamic significance or HSPDA. Receiver operating characteristic (ROC) curves showed indexed LA volumes and LA/RA volume ratios to have moderate power to discriminate HSPDA from low hemodynamic burden PDA. Classic LA:Ao ratio, combined atrial volumes, and RA volumes yielded ROC areas that appeared less promising as discriminators for HSPDA. Atrial volume measurements in neonates and infants have a linear association with body surface area and show acceptable inter- and intraobserver agreement. Indexed LA volume and LA/RA volume ratio are potentially useful markers for HSPDA. RA dilation due to left to right shunting through the patent foramen ovale as quantified by RA volume measurements does not appear to be an important marker for HSPDA.

Efficacy of Double and Triple Phototherapy in Term Newborns With Hyperbilirubinemia: The First Clinical Trial

Icterus is the most common medical problem in neonates and phototherapy is the standard treatment for neonatal hyperbilirubinemia. This study aimed to compare the efficacy and length of hospital stay of double and triple phototherapy in newborns with indirect hyperbilirubinemia. In a clinical trial, 40 healthy term newborns (gestational age >37 weeks) with bilirubin > or =12 and > or =15 mg/dL in the second and third day, respectively, were randomly assigned to triple (n=20) or double phototherapy (n=20) groups. Total and direct serum bilirubin were measured at admission, 8, 16, and 24 hours after beginning of phototherapy, and every 12 hours thereafter until discharge (when bilirubin levels reached < or =10 mg/dL). There were 21 male (52%) and 19 female (48%) term neonates, with significant difference between patients' age, weight, and age of icterus. There was no significant difference in the rate of bilirubin decline between the two groups within the first 8, 16 and 24 hours. There was no significant difference in mean length of hospital stay between the two groups. Analysis of complications showed no difference between triple and double groups. Triple phototherapy failed to reduce total serum bilirubin and shorten length of hospitalization more rapidly than double phototherapy.

Handbook for Stoelting’s Anesthesia and Co-Existing Disease, 3rd Edition.

Mayo Clinic, Rochester, Minnesota. kenyon.christine2@mayo.eduHandbook for Stoelting’s Anesthesia and Co-Existing Disease, 3rd Edition. Edited by Roberta L. Hines, M.D., and Katherine E. Marschall, M.D. Philadelphia, Saunders Elsevier, 2009. Pages: 510. Price: $54.95.This handbook accompanies the fifth edition of Stoelting’s Anesthesia and Co-Existing Disease , containing the same topics and chapters as the main textbook. This format makes it easy to reference the textbook for more detailed information, while the handbook provides a concise, portable reference that is easy to use in the operating room. Written by 28 expert authors, the book is divided by organ system into 25 chapters.Chapters 1–8 discuss ischemic heart disease, valvular heart disease, congenital heart disease, abnormalities of cardiac conduction and cardiac rhythm, systemic and pulmonary arterial hypertension, heart failure and cardiomyopathies, pericardial diseases and cardiac trauma, and vascular diseases. Major anesthetic considerations and hemodynamic goals are presented for patients with ischemic heart disease, stenotic and regurgitant valvular lesions, congenital heart disease, and rhythm abnormalities. A wide variety of vascular diseases, from abdominal aortic aneurysms to Takayasu’s arteritis, Wegener’s granulomatosis, and polyarteritis nodosa, are reviewed with several helpful tables that present signs, symptoms, and anesthetic considerations of these conditions.The chapter on respiratory diseases, Chapter 9, includes helpful figures, such as both normal and abnormal spirometry and flow-volume curves, along with a review of the diagnostic and therapeutic considerations for both obstructive and restrictive lung diseases. Modes of mechanical ventilation and techniques for weaning from the ventilator are described in a concise, easy-to-read manner.Chapter 10 is divided into three parts: diseases affecting the brain, spinal cord disorders, and diseases of the autonomic and peripheral nervous systems. Increased intracranial pressure, brain tumors, coma, brain death, cerebrovascular diseases, traumatic brain injury, and seizure disorders are discussed with a focus on anesthetic management. A section devoted to spinal cord disorders provides guidelines to the management of both acute and chronic spinal cord injury, including a section on autonomic hyperreflexia. Finally, autonomic disorders and peripheral neuropathies are discussed.Chapters 11–22 are devoted to diseases of the liver and biliary tract; diseases of the gastrointestinal system; nutritional diseases and inborn errors of metabolism; renal diseases; fluid, electrolyte, and acid-base disorders; endocrine diseases; hematologic disorders; skin and musculoskeletal diseases; infectious diseases; cancer; diseases related to immune system dysfunction; and psychiatric diseases/substance abuse/drug overdose. Each chapter describes the most common diseases in each of these systems, along with their anesthetic considerations.Chapter 23 discusses care of the obstetric patient, including the normal physiologic changes associated with pregnancy and options for obstetric anesthesia care. Complications, such as preeclampsia and obstetric hemorrhage, are reviewed, along with considerations for obstetric patients with coexisting medical diseases. Fetal assessment and common neonatal problems are discussed briefly.Chapter 24 provides a relatively thorough review of pediatric anesthesiology with topics such as the physiologic differences between children and adults, guidelines for intraoperative fluid management and acceptable blood loss, and pharmacologic considerations in pediatric patients. Neonatal conditions, including respiratory distress syndrome, retinopathy of prematurity, congenital diaphragmatic hernia, tracheoesophageal fistula, omphalocele/gastroschisis, and pyloric stenosis, are reviewed with a focus on anesthetic management. Pediatric surgical conditions such as posterior fossa tumors, craniosynostosis, cleft lip/palate, mediastinal masses, and burn injuries are also discussed. In addition, there is an excellent review of malignant hyperthermia and masseter muscle rigidity, which incorporates several concise, easy-to-reference tables.The final chapter of the handbook discusses geriatric disorders, with a helpful table describing the effects of aging on each organ system. Considerations for patients with both dementia and delirium are reviewed, as are ethical challenges in geriatric anesthesia.Overall, this handbook is a compact, portable reference for questions and conditions most commonly encountered in anesthesia. One especially helpful feature of the book is the multitude of tables that present critical information in a concise format. These succinct tables quickly provide the anesthesiologist with the most important perioperative concerns and goals for patients with a wide variety of conditions. The handbook has been revised with current information, such as the recently updated guidelines for endocarditis prophylaxis. As a concise, easy-to-read handbook, this text is a valuable tool for experienced anesthesiologists, fellows, and residents to use in the operating room and preoperative clinic.Mayo Clinic, Rochester, Minnesota. kenyon.christine2@mayo.edu

The acutely ill child or neonate

Abstract This article covers four major topics in paediatrics. Knowledge of their management is important for any Foundation Doctor working within the paediatric department. The febrile child is a common referral to any paediatric unit. Most febrile children are suffering from simple viral illnesses, but occasionally a fever is a sign of a life-threatening illness, such as meningitis. If meningitis is suspected, it is vital to carry out appropriate investigations before treatment is started. There are multiple causes of meningitis, so accurate interpretation of investigations is important in order to manage children appropriately. Diabetes is a complex multi-systemic condition, which has an increasing incidence. There are many pitfalls in its management, both on first presentation and in long-term care. Diabetic ketoacidosis (DKA) continues to have a significant mortality if not recognised early and treated appropriately. Neonatology is a vast subject that can only be touched upon in this article. Junior doctors working within paediatrics are often the first port of call for problems on postnatal wards, and therefore need to have a basic understanding of common neonatal problems to initiate management.

Immature Platelet Fraction (IPF) as Novel Laboratory Parameter for Managing Early Onset Thrombocytopenia in Very Low Birth Weight Infants

Thrombocytopenia (platelet count <150/nl) is one of the most common hematologic problems in preterm and term neonates and affects 18 to 35% of all patients admitted to neonatal intensive care units (NICU). Thrombocytopenia is more than twice common in extremely low birth weight infants (ELBW; <1000g) as reported among the general NICU population. Among thrombocytopenic ELBW infants almost 40% suffer from severe thrombocytopenia as defined by a platelet count <50nl. The risk for hemorrhage, which may cause acute life-threatening complications and/or life-long disability in more than 15%, is difficult to assess, because it is closely related to the gestational and postnatal age of the neonate as well as the cause of the thrombocytopenia and the severity of concurrent conditions. From routine full blood counts of premature (birth weight <1500g) and full term babies we additionally determined platelet counts, IPF, MPV, NRBC and reticulocyte counts. On the basis of individual IPF and platelet counts we were able to predict the platelet counts of the following day. In non-thrombocytopenic preterm and term neonates no significant changes in IPF values were found during the first week of life. In the first week, thrombocytopenic neonates displayed higher IPF values than neonates with normal plaletet counts. We hypothesize that IPF is higher in neonates with chronic hypoxia as leading cause for thrombocytopenia and lower in case of perinatal infections. IPF could be a novel parameter in routine diagnostics available at a 24/7 basis in VLBW infants and may be valuable in identifying the underlying pathomechanism of various thrombocytopenias and in clinical decision making on platelet transfusions.

General paediatric surgery in Ireland: a crisis in evolution

In their recently published editorial, Coakley and Grace [1] identify the provision of paediatric surgical services in Ireland as a crisis in evolution. This is based on the case report of a child who could not be anaesthetised because of lack of paediatric anaesthesia, the demise of older general surgeons who received paediatric training or indeed operated on a wide range of conditions in their clinical practices, the lack of uptake of training opportunities in paediatric surgery by general surgery trainees and the increasing development of subspecialisation. The option provided is that we should perhaps move to a system of having three paediatric surgical hospitals similar to the Scottish model. The issues outlined in this paper are very real and deserve the strongest debate among surgeons and health care providers in this country. The recent debate about cancer outcomes and the development of cancer centres are driven by the same needs—expert provision of care by multidisciplinary teams in well-resourced environments with appropriate quality assurance parameters and outcome expectation. The paper by Coakley and Grace also touches on the often-overlooked needs of equity of access across the country. It seems clear that there are three issues that must be addressed—ease of access to care for common emergencies (such as appendicitis) in young patients, provision of surgical care in large hospitals for very young children (cases such as pyloric stenosis, undescended testis, hernias in young children) and tertiary level care for pure paediatric and complex surgery (for example, exomphalos, cardiac surgery). It would appear that the national policy for the latter is to have a national Paediatric Hospital delivering tertiary level care. The provision of care for common paediatric surgical problems such as level 2 issues would seem to me to involve having surgeons trained in paediatrics working in the major teaching /regional hospitals with attached maternity units. Currently, some of these hospitals have appropriately trained general surgeons providing such care. The delivery of care to paediatric patients with common conditions such as tonsillitis, common fractures, appendicitis, etc. involves subspecialist paediatric surgical expertise, especially support from anaesthesiology, intensive care and paediatrics. These services have to be delivered by trained surgeons working in an appropriate environment. The recent publication of the Children’s Surgical Forum Report by the Royal College of England [2] documents current practice and identifies the way forward for Britain and Northern Ireland. It clearly demonstrates the need for effective clinical networks. These would incorporate the national supra-regional centre dealing with rare and more complex cases, regional centres and smaller district general hospitals. It suggests that even smaller-sized district general hospitals will be able to provide support for surgical activity even in the absence of resident paediatricians by having robust cover arrangements in place. The role of general surgeons in the management of common neonatal problems is open to debate. The development of specialist paediatric surgery and transfer to specialist centres has resulted in reduction of the numbers of surgeons dealing with this problem outside non-specialist centres. Clearly this type of surgery is best done by experienced surgeons in an environment where specialised multidisciplinary support from anaesthesia and neonatal intensive care is readily available. M. J. Kerin (&) Department of Surgery, Clinical Science Institute, University College Hospital, Galway, Ireland e-mail: michael.kerin@nuigalway.ie

Pulmonary Circulation and Pulmonary Function in Neonatal Lung Hypoplasia:Treatment with Corticosteroids

Lung hypoplasia (LH) is a common neonatal problem resulting from small, structurally immature lungs. LH is a graded condition which, if severe, is life threatening due to impairment of ventilation, pulmonary blood flow and gas exchange. Although the effects of LH on the structure of lung parenchyma have been well defined in a number of species, little is known about its structural or functional effects on the pulmonary vasculature. Using an ovine model of bilateral LH we have studied pulmonary vascular development and blood flow in relation to ventilatory performance and lung mechanics. LH greatly increases pulmonary vascular resistance and is associated with evidence of impaired development of the pulmonary vasculature, and decreased mRNA levels of vascular growth factors such as PDGF and PECAM-1. Many studies have shown that antenatal corticosteroid treatment has a beneficial effect on lung development and the perinatal transition. In neonatal sheep with LH, lung compliance is not affected by a single dose of antenatal corticosteroids but pulmonary vascular resistance is significantly reduced, and mRNA expressions of PDGF and PECAM-1 normalised. It is clear that antenatal corticosteroids could be a promising treatment option for infants experiencing difficulties with perinatal adaptation of the pulmonary circulation associated with LH and other pathological respiratory conditions. Keywords: Lung hypoplasia, fetus, newborn, corticosteroids, pulmonary blood flow, persistent pulmonary hypertension of the newborn

From the editors

From the editors

A PHASE 1 TRIAL TESTING AN ENTERAL SOLUTION PATTERNED AFTER HUMAN AMNIOTIC FLUID TO TREAT FEEDING INTOLERANCE

Feeding intolerance is a common problem in neonates; in some cases it may be related to atrophic changes in the small bowel mucosa. In these infants, feeding tolerance might improve after oral administration of enterocyte growth factors in a sterile, isotonic, noncaloric solution patterned after human amniotic fluid. Ten infants who met the study criteria for feeding intolerance were enrolled in this pilot trial. The test solution was administered, 2.5 mL/kg every 3 hours, until 80 mL/kg/day of milk feedings were tolerated, or for a maximum of 7 days. When milk feedings were prescribed, they were mixed with the test solution. Volumes of milk feedings were increased in amounts determined by the attending neonatologist and neonatal nurse practitioner. The outcome was the net average enteral kilocalories per kilogram of body weight per day (kcal/kg/day) for 3 periods: (1) the 3 days before the test treatment was begun, (2) the days the test treatment was administered, and (3) the 7 days following cessation of the test treatment. At study entry the infants' chronological ages ranged from 3 to 65 days. All infants tolerated the test solution, which was given for a mean of 5 days (range 3 to 7 days). During that period, the infants received more enteral calories (mean 18 kcal/kg/day, range 1 to 32) than during the preceding 3 day period (mean 3 kcal/kg/day, range 0 to 7, P < 0.05). During the 7 days following the test treatment the infants received 87 enteral kcal/kg/day (range 11 to 109, P < 0.02 compared to the treatment period). In this Phase 1 pilot trial, 10 heterogeneous infants in the neonatal intensive care unit with feeding intolerance had a significant increase in milk feedings after treatment with a sterile, isotonic, noncaloric solution patterned after human amniotic fluid.

Failure of cholecystokinin-octapeptide to prevent TPN-associated gallstone disease

Purpose Gallstone formation is a common problem in neonates on prolonged courses of total parenteral nutrition (TPN). The authors hypothesized that the use of cholecystokinin-octapeptide (CCK), given at the time of TPN administration, would prevent gallstone formation in a high-risk group of patients with TPN. Methods A prospective, randomized, blinded, controlled trial of neonates who were on a prolonged course of TPN for prematurity (25 infants), necrotizing enterocolitis (NEC, 8 infants), or abdominal surgery (5 infants) were selected randomly to receive CCK vs placebo. Patients remained on the study until taking more than 50% of energy enterally. Children were recalled between 2 and 4 years after completing TPN for ultrasonographic examination of their hepatobiliary tree. Results Neonates (38 studied) required a mean (±SD) of 33 ± 16 days of TPN. Cholelithiasis was detected in 4 (10%) infants. Cholecystokinin-octapeptide was not effective in preventing the formation of gallstones (3 stones in infants receiving CCK, P = .51). Diagnosis ( P = .56), birth weight ( P = .54), gestational age ( P = .18), and duration of TPN ( P = .53) did not correlate with gallstone formation. To address the management of these stones, all 4 were placed on a prolonged course of ursodeoxycholic acid (mean duration, 11.6 ± 5.4 months). Two additional infants (not in the original study) with TPN-associated gallstone disease were also given a trial of ursodeoxycholic acid. Serial ultrasounds were performed every 6 months. No patient achieved any degree of stone dissolution. One patient underwent cholecystectomy for symptomatology. Conclusions Total parenteral nutrition–associated gallstones were detected in 10% of children, and most are nonsymptomatic. Cholecystokinin-octapeptide prophylaxis was not effective in preventing TPN-associated gallstones. In addition, the use of ursodeoxycholic acid did not dissolve gallstones, once identified. Future methods will be needed to address the prevention and treatment of these stones.

Metabolic Disorders Associated With Neonatal Hypoglycemia

After completing this article, readers should be able to: 1. Describe four sources of glucose available to the neonate in the first 24 postnatal hours. 2. Select the best routine diagnostic test to recognize fatty acid oxidation defects. 3. List three or more metabolic disorders that can be identified by newborn screening performed using tandem mass spectrometry. Hypoglycemia is a common problem in neonates that has many causes. This review focuses on metabolic disorders that may be associated with hypoglycemia in the neonatal period. During intrauterine life, the fetus derives fuel, as glucose, from the mother via the placenta. After birth, the energy demands on the former fetus increase dramatically. The baby now must maintain its own body temperature and must undertake the work of breathing and other activities. Further, the maintenance of blood glucose levels requires glycogenolysis and gluconeogenesis. Postnatally, there are four sources of glucose: dietary glucose; glucose derived from the cleavage of more complex sugars in the gut (eg, lactose to glucose and galactose); glucose released from glycogen stores (primarily in the liver); and gluconeogenesis, in which glucose is synthesized from carbon skeletons derived from certain amino acids using energy derived from catabolism of fatty acids. Most term infants have sufficient glycogen stores to maintain blood glucose levels for several hours before gluconeogenesis is required. Infants who are breastfed in the United States typically are offered only water as a supplement to human milk during the first few postnatal days, a period when the mother’s milk supply is not yet established. In contrast, formula-fed babies receive calories by mouth by the end of the first postnatal day. Consequently, the metabolic stress of prolonged fasting occurs more frequently in breastfed than in formula-fed babies. Although breastfed babies have higher levels of ketone bodies that appear to provide adequate energy during this …

167 Babylink - A Web Based Tool to Improve Communication between Clinicians and Parents in A Neonatal Unit

Background: There is an ever-increasing demand for improved communication with parents and their families. At present, parents gather information from multiple sources, which can lead to incorrect and/or inconsistent advice and information being received. The aim of this project was to develop, and evaluate a system that gives parents secure access via the internet to clinical information, extracted automatically from the electronic patient record and presented in a format appropriate to parents. Method: Software has been written that searches the electronic record for any information specified by the system administrator, such as diagnoses, treatments and records of communication. The system then links automatically to a library of short parent information templates and creates a parent report that is clinically relevant to the problems of the individual baby. The administrator can define the format of the reports, as well as the frequency and time interval sampled. Reports are encrypted and sent to an internet server. Parents access the reports on the Babylink website ( www.babylink.info/edinburgh ), using their own log-in and password. They can also view their baby's diary, which contains photographs and non-clinical messages written by the staff. The web-site has an open area providing general details about the neonatal unit and generic information about common neonatal problems. As part of data validation, reports have been checked manually for accuracy. Parents can comment or ask specific questions about their baby on-line. This feedback has been used to develop the website and the content of the reports. The project was approved by the local ethics committee and parents give written, informed consent before information is forwarded to the website. Results: The reports and diaries have been successfully implemented. To date the system has been live for 6 weeks. 23 families have been accessing reports on the internet. Two refused to be involved. There has been no negative feedback, with parents expressing very positive views. Many constructive comments have helped develop the website and the parent reports. Conclusions: This system offers the facility for parents to access specific, up to date information about their baby. It can be used with any electronic record system from which data can be exported. Further developments include prospective tailored information about discharge planning and care of the baby at home. The effect of the system on parental perceptions of communication is being evaluated.